Foraminoplasty Performed with a Trephine and a New Tool in Transforaminal Endoscopic Lumbar Discectomy: A Single-Center Retrospective Study

Abstract

Objective:: Foraminoplasty is an important step in transforaminal endoscopic lumbar discectomy (TELD). A trephine is widely used in foraminoplasty. However, foraminoplasty using a trephine alone sometimes fails to remove the resected bone, resulting in the bone remaining in the foramen or spinal canal, which can potentially cause neurological irritation or injury. The objective of this study is to introduce a self-designed tool, referred to as an anchoring drill, for use with a trephine in foraminoplasty in TELD and to evaluate its advantages.

Methods:: A retrospective review was performed to identify patients who underwent L4–5 TELD between January 2019 to January 2022. Foraminoplasty was performed in all patients. Depending on whether the anchoring drill was used or not, patients were divided into two groups. Surgery-related parameters and complications were reviewed. Visual analog scale (VAS) and Japanese Orthopaedic Association (JOA) scores were also assessed for all patients. SPSS statistical software was used for statistical calculation.

Results:: A total of 100 patients were included (55 in the anchoring drill group and 45 in the trephine group). The incidence of residual bone fragments after foraminoplasty of the anchoring drill group was 9.09%, which was lower than that of the trephine group, at 33.33% (p < 0.05). The mean endoscopic operation time of the anchoring drill group was shorter than that of the trephine group (p < 0.05). The mean fluoroscopy time and duration of foraminoplasty showed no significant differences between the two cohorts. The total perioperative complication incidence was lower in the anchoring drill group, in which the neural irritation incidence showed a significant difference (anchoring drill group: 3.64%, trephine group: 17.78%, p < 0.05). VAS and JOA scores were significantly improved after the operation for all patients (p < 0.001), however, no statistical differences were found between the two groups at each follow-up visit.

Conclusion:: The combination of a trephine with an anchor drill was demonstrated to be safe and effective in foraminoplasty in TELD, improving the success rate of foraminoplasty and reducing neurological complications compared to using trephine alone.

Keywords

foraminoplasty / lumbar disc herniation / superior articular process / transforaminal endoscopic lumbar discectomy / trephine

References

[1] Hermantin FU, Peters T, Quartararo L, Kambin P. A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. J Bone Joint Surg Am. 1999;81:958–965.

[2] Maroon JC. Current concepts in minimally invasive discectomy. Neurosurgery. 2002;51:S137–S145.

[3] Yeung AT, Tsou PM. Posterolateral endoscopic excision for lumbar disc herniation: surgical technique, outcome, and complications in 307 consecutive cases. Spine (Phila Pa 1976). 2002;27:722–731.

[4] Hoogland T, Schubert M, Miklitz B, Ramirez A. Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain: a prospective randomized study in 280 consecutive cases. Spine (Phila Pa 1976). 2006;31:E890–E897.

[5] Choi G, Lee SH, Lokhande P, Kong BJ, Shim CS, Jung B, et al. Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope. Spine (Phila Pa 1976). 2008;33:E508–E515.

[6] Henmi T, Terai T, Hibino N, Yoshioka S, Kondo K, Goda Y, et al. Percutaneous endoscopic lumbar discectomy utilizing ventral epiduroscopic observation technique and foraminoplasty for transligamentous extruded nucleus pulposus: technical note. J Neurosurg Spine. 2016;24:275–280.

[7] Telfeian AE, Veeravagu A, Oyelese AA, Gokaslan ZL. A brief history of endoscopic spine surgery. Neurosurg Focus. 2016;40:E2.

[8] Wen BT, Zhang XF, Wang Y, Zhang X-f, Wang Y, Xiao S-h, et al. Complication and treatment of the lumbar intervertebral disc herniation using percutaneous endoscopic lumbar discectomy. Zhonghua Wai Ke Za Zhi. 2011;49:1091–1095.

[9] Chen X, Chamoli U, Lapkin S, Castillo JV, Diwan AD. Complication rates of different discectomy techniques for the treatment of lumbar disc herniation: a network meta-analysis. Eur Spine J. 2019;28:2588–2601.

[10] Feng F, Xu Q, Yan F, Xie Y, Deng Z, Hu C, et al. Comparison of 7 surgical interventions for lumbar disc herniation: a network meta-analysis. Pain Physician. 2017;20:E863–E871.

[11] Zhao Y, Yuan S, Tian Y, Liu X. Necessity of routinely performing foraminoplasty during percutaneous endoscopic transforaminal discectomy (PETD) for lumbar disc herniation. Br J Neurosurg. 2020;37:1–7.

[12] Knight MT, Jago I, Norris C, Midwinter L, Boynes C. Transforaminal endoscopic lumbar decompression & foraminoplasty: a 10 year prospective survivability outcome study of the treatment of foraminal stenosis and failed back surgery. Int J Spine Surg. 2014;8:8.

[13] Yang JS, Chu L, Chen CM, Wang XF, Xie PG, Deng R, et al. Foraminoplasty at the tip or base of the superior articular process for lateral recess stenosis in percutaneous endoscopic lumbar discectomy: a multicenter, retrospective, controlled study with 2-year follow-up. Biomed Res Int. 2018;2018:7692794.

[14] Li ZZ, Hou SX, Shang WL, Song KR, Zhao HL. Modified percutaneous lumbar foraminoplasty and percutaneous endoscopic lumbar discectomy: instrument design, technique notes, and 5 years follow-up. Pain Physician. 2017;20:E85–E98.

[15] Li ZZ, Hou SX, Shang WL, Cao Z, Zhao HL. Percutaneous lumbar foraminoplasty and percutaneous endoscopic lumbar decompression for lateral recess stenosis through transforaminal approach: technique notes and 2 years follow-up. Clin Neurol Neurosurg. 2016;143:90–94.

[16] Xie P, Feng F, Chen Z, He L, Yang B, Chen R, et al. Percutaneous transforaminal full endoscopic decompression for the treatment of lumbar spinal stenosis. BMC Musculoskelet Disord. 2020;21:546.

[17] Bao BX, Zhou JW, Yu PF, Chi C, Qiang H, Yan H. Transforaminal endoscopic discectomy and foraminoplasty for treating central lumbar stenosis. Orthop Surg. 2019;11:1093–1100.

[18] Schubert M, Hoogland T. Endoscopic transforaminal nucleotomy with foraminoplasty for lumbar disk herniation. Oper Orthop Traumatol. 2005;17:641–661.

[19] Wu B, Zhan G, Tian X, Fan L, Jiang C, Deepti B, et al. Comparison of transforaminal percutaneous endoscopic lumbar discectomy with and without foraminoplasty for lumbar disc herniation: a 2-year follow-up. Pain Res Manag. 2019;2019:6924941.

[20] Chen C, Ma X, Zhao D, Yang H, Xu B, Wang Z, et al. Full endoscopic lumbar foraminoplasty with periendoscopic visualized trephine technique for lumbar disc herniation with migration and/or foraminal or lateral recess stenosis. World Neurosurg. 2021;148:e658–e666.

[21] Henmi T, Terai T, Nagamachi A, Sairyo K. Morphometric changes of the lumbar intervertebral foramen after percutaneous endoscopic foraminoplasty under local anesthesia. J Neurol Surg A Cent Eur Neurosurg. 2018;79:19–24.

[22] Chung J, Kong C, Sun W, Kim D, Kim H, Jeong H. Percutaneous endoscopic lumbar foraminoplasty for lumbar foraminal stenosis of elderly patients with unilateral radiculopathy: radiographic changes in magnetic resonance images. J Neurol Surg A Cent Eur Neurosurg. 2019;80:302–311.

[23] Ruetten S, Komp M, Godolias G. An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the full-endoscopic uniportal transforaminal approach-technique and prospective results of 463 patients. Spine (Phila Pa 1976). 2005;30:2570–2578.

[24] Tsou PM, Yeung AT. Transforaminal endoscopic decompression for radiculopathy secondary to intracanal noncontained lumbar disc herniations: outcome and technique. Spine J. 2002;2:41–48.

[25] Liu X, Peng Y. A novel Foraminoplasty technique for posterolateral percutaneous transforaminal endoscopic lumbar surgery. Oper Neurosurg (Hagerstown). 2020;19:E11–E18.

[26] Kondo M, Oshima Y, Inoue H, Takano Y, Inanami H, Koga H. Significance and pitfalls of percutaneous endoscopic lumbar discectomy for large central lumbar disc herniation. J Spine Surg. 2018;4:79–85.

[27] Lee CW, Yoon KJ, Ha SS, Kang JK. Foraminoplastic superior vertebral notch approach with reamers in percutaneous endoscopic lumbar discectomy: technical note and clinical outcome in limited indications of percutaneous endoscopic lumbar discectomy. J Korean Neurosurg Soc. 2016;59:172–181.

[28] Shu W, Wang H, Zhu H, Li Y, Zhang J, Lu G, et al. Nerve root entrapment with pseudomeningocele after percutaneous endoscopic lumbar discectomy: a case report. J Spinal Cord Med. 2020;43:552–555.

[29] Lewandrowski KU. "Outside-in" technique, clinical results, and indications with transforaminal lumbar endoscopic surgery: a retrospective study on 220 patients on applied radiographic classification of foraminal spinal stenosis. Int J Spine Surg. 2014;8:26.

[30] Yeung AT. The evolution and advancement of endoscopic foraminal surgery: one surgeon's experience incorporating adjunctive Techologies. SAS J. 2007;1:108–117.

[31] Ouyang ZH, Tang M, Li HW, Zou MX, Li XL, Wang WJ, et al. Full-endoscopic foraminoplasty using a visualized bone reamer in the treatment of lumbar disc herniation: a retrospective study of 80 cases. World Neurosurg. 2021;149:e292–e297.

[32] Lin YP, Wang SL, Hu WX, Chen BL, du YX, Zhao S, et al. Percutaneous full-endoscopic lumbar foraminoplasty and decompression by using a visualization reamer for lumbar lateral recess and foraminal stenosis in elderly patients. World Neurosurg. 2020;136:e83–e89.

[33] Ba Z, Li Z, Liu Z, Li H, Wu D, Zhu J. Eccentric technique for foraminoplasty in percutaneous endoscopic transforaminal procedure: a technical note. Int J Surg. 2017;46:110–113.

[34] Hsu HT, Chang SJ, Yang SS, Chai CL. Learning curve of full-endoscopic lumbar discectomy. Eur Spine J. 2013;22:727–733.

[35] Wang B, Lu G, Patel AA, Ren P, Cheng I. An evaluation of the learning curve for a complex surgical technique: the full endoscopic interlaminar approach for lumbar disc herniations. Spine J. 2011;11:122–130.

[36] Fan G, Gu X, Liu Y, Wu X, Zhang H, Gu G, et al. Lower learning difficulty and fluoroscopy reduction of transforaminal percutaneous endoscopic lumbar discectomy with an accurate preoperative location method. Pain Physician. 2016;19:E1123–E1134.

[37] Fang G, Ding Z, Song Z. Comparison of the effects of epidural anesthesia and local anesthesia in lumbar transforaminal endoscopic surgery. Pain Physician. 2016;19:E1001–E1004.

[38] Gibson JNA, Subramanian AS, Scott CEH. A randomised controlled trial of transforaminal endoscopic discectomy vs microdiscectomy. Eur Spine J. 2017;26:847–856.

[39] Ahn SS, Kim SH, Kim DW, Lee BH. Comparison of outcomes of percutaneous endoscopic lumbar discectomy and open lumbar microdiscectomy for young adults: a retrospective matched cohort study. World Neurosurg. 2016;86:250–258.

[40] Hua W, Zhang Y, Wu X, Gao Y, Li S, Wang K, et al. Full-endoscopic visualized foraminoplasty and discectomy under general anesthesia in the treatment of L4-L5 and L5-S1 disc herniation. Spine (Phila Pa 1976). 2019;44:E984–E991.

[41] He J, Tang J, Jiang X, Ren H, Cui J, Liang Z, et al. Efficacy and safety of foraminoplasty performed using an endoscopic drill to treat axillary disc herniation. World Neurosurg. 2020;138:e413–e419.

[42] Ju CI. Technical considerations of the transforaminal approach for lumbar disk herniation. World Neurosurg. 2021;145:597–611.

RIGHTS & PERMISSIONS

2024 2024 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.